Fillable PLAN REVIEW APPLICATION PROCESS NOTICE (Maricopa County Telecommunications)

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PLAN REVIEW APPLICATION PROCESS NOTICE (Maricopa County Telecommunications)

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OC Plan Review Application in fillable form; Process Notice (Page 1 Only) Page 1 of 3 Revised December 2012
ENVIRONMENTAL SERVICES DEPARTMENT
Darcy Kober, R.S., Director
501 N. 44th St., Suite 200
Phoenix, AZ 85008
TT (602) 506-6704
WATER & WASTE MANAGEMENT DIVISION
Eric Matson, P.E., Division Manager
Kenyata Mangar, R.S., Drinking Water Program Manager
(602) 506-6935
FAX (602) 372
-
0866
PLAN REVIEW APPLICATION PROCESS NOTICE
Operational or Compliance Plan Review
Operational and Compliance Plan Review are required for all public water systems (PWS). Although this
application is typically used for PWS Site Sampling, Emergency Operations, and Backflow Prevention Plans, it
may be used for all types of operational and compliance plan review submittals. For complete operational and
compliance plan requirements for public water systems, please refer to Arizona Administrative Code Title 18,
Chapters 4. Copies are available from the office of the Arizona Secretary of State or online at www.azsos.gov.
This application must be completed by the public water system (PWS) Permit Owner/Holder or authorized
representative of the PWS and submitted with the applicable written Operational or Compliance Plan (OC Plan)
to be reviewed and schedule plan review fee.
Plan Review Process Steps:
1. Applicant submits completed OC Plan Review Application, OC Plan, and appropriate scheduled fee.
2. Department conducts review of the OC application and plan to determine approvability of the OC Plan.
3. Applicant is provided with Department’s decision of “approval” or “disapproval” based on step 2.
The Department will approve or deny this application in 83 business days (16 day - Administrative Review, 67 day -
Substantive Review) excluding any days the application is returned to the applicant for additional information. You may
request a clarification from the Department of its interpretation or application of a statute, ordinance, regulation,
delegation agreement or authorized substantive policy statement as provided in A.R.S. §11-1609. Contact us by e-mail,
regular mail, telephone, or in person at the address listed at the top of the page, marked attention Drinking Water Program
(DWP). The DWP Application Clerk is the contact for information regarding this application and can be reached at
(602)506-6935 or sdwquestions@mail.maricopa.gov with any questions. Additional application information may
also be
found on our program website at http://www.maricopa.gov/2350/Drinking-Water.
Maricopa County Environmental Services Department
For Internal Use Only
CAP ID DWR- Staff Assigned
OC Plan Review Application in fillable form Page 2 of 3 Revised December 2012
APPLICATION FOR
PWS Operational or Compliance Plan Review
All fields are required to be completed. Incomplete applications will not be accepted.
Please Note: This application form must be completed by an authorized representative of the public water system and
submitted with applicable written Operational or Compliance Plan to be reviewed and scheduled plan review fee.
Proposed Public Water System (PWS) Information
PWS Name :
PWS Address:
PWS ID#: 07- Type of PWS: Community
Non-transient
Transient
Population served:
Service Connections:
Initial Monitoring Date:
Plan Review Information
Plan Type Included for Review
(Check One)
: Site Sampling Emergency Operations Backflow Prevention
Rules Addressed in Plan:
(check all that apply)
IDSE Stage 2 TCR GWR SWTR Lead and Copper
Other (List):
Standard Review Expedited Review Plan Comments:
PWS Permit Owner/Holder (PO) Information
PO Name: PO Contact Name:
Address:
Phone #: Fax #:
Cell #:
Email:
PWS Permit Billing (PB) Information
Billing Contact Name: Title:
Billing Address:
Phone #:
Fax #:
Cell #:
Email:
PWS Primary Certified Operator (CO) Information
Primary Certified Operator: License Number:
CO Business Name:
Address:
Phone #:
Fax #:
Cell #:
Email:
Professional Engineer (PE) Information
PE Name: License Number:
PE Business Name:
Address:
Phone #:
Fax #:
Cell #:
Email:
Mail approval to:
Public Water System Owner PWS Certified Operator Project Engineer
Pursuant to A.R.S. § 41-1009, the Department may enter your establishment to conduct inspections. You have the right to receive a
copy of the Department’s inspection report at the time of the inspection, within thirty (30) days after the inspection, or as otherwise
provided by federal law. By initialing below, I agree that the Department may send me a copy of its inspection report by e-mail to the
following email address: or by facsimile transmission to the following fax number : .
(Permit Owner/Holder initials) .
It is the responsibility of the permit holder to update the Department if there is a change in contact information.
PWS Permit Owner/ Holder*:
(Person with Fiduciary Responsibility)
Name (Print) Signature
Date
(*Attached Letter of Authorization required if application is not signed by Permit Owner/Holder)
Maricopa County Environmental Services Department
For Internal Use Only
CAP ID DWR- Staff Assigned
OC Plan Review Application in fillable form Page 3 of 3 Revised December 2012
Letter of Authorization
Complete this form if the Permit Owner/Holder is not signing the attached application.
This form is effective for one (1) year from the date of Permit Owner/Holder signature.
All fields are required. Incomplete applications will not be accepted.
Permit Information
Permit Name:
Permit #:
Permit Type:
Permit Address:
Permit Owner/Holder (PO) Information
PO Name:
PO Address:
Phone #:
Fax #:
Cell #:
Email:
Authorized Agent (AA) Information
AA Name:
AA Title:
AA Firm Name:
Address:
Phone #:
Fax #:
Cell #:
Email:
I hereby authorize
of
(firm name)
to file a/an
application
and act on my behalf during the application process.
Permit Owner/Holder Signature:
Date:
Authorized Agent Signature:
Date:
Witness Name (Print)
Witness Signature
Date:
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PLAN REVIEW APPLICATION PROCESS NOTICE (Maricopa County Telecommunications)

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Completed 6 August 2020

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